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In 2001, western Europe faces an endemic situation
for AIDS (22.8 cases per million population) and for HIV infection (54.9
cases per million), the most affected groups remaining injecting drug
users and the homo/bisexual men. However, numbers of new HIV diagnoses
are increasing among persons infected through heterosexual contact. Central
Europe have been relatively spared, with AIDS incidence under 6 cases
per million per year, and new HIV diagnoses between 7 and 10 cases per
million. On the other hand, eastern Europe shows an epidemic increase
in the number of newly diagnosed HIV infections (233 cases in 1994, around
100 000 reported cases in 2001, ie 349 cases per million population) affecting
all countries.

Introduction

European HIV/AIDS surveillance started in 1984 with the European Centre
for the Epidemiological Surveillance of AIDS (EuroHIV) and the reporting
of AIDS cases by 17 countries1. It aims at understanding, improving
and sharing HIV-AIDS surveillance data to optimise the prevention, control
and management of the disease. This network gradually extended to the
51 member countries of the World Health Organization European Region.
After reporting AIDS cases, most European countries have implemented
the notification of HIV seropositivity at different dates (1). However,
the three countries most affected in the West (France, Italy, and Spain)
still have no notification system to report HIV infection at the national
level2. This article presents surveillance data on AIDS cases and new
diagnoses of HIV infection reported by 30 June 2002 (2).

Methods
Standardised and anonymous data on AIDS cases and new HIV diagnoses
as well as the prevalence of HIV infection in target populations (such
as injecting drug users (IDU)) are collected every six months through
the national coordinators of HIV/AIDS surveillance in the 51 European
countries (3). These data are then analysed and published in the six
monthly report "Surveillance of HIV/AIDS in Europe" (www.eurohiv.org).
To take into account the diversity of the epidemiological situation
in the WHO European region, the 51 countries have been classified into
three geographical areas: the West (the 15 countries of the European
Union, plus Andorra, Iceland, Israel, Malta, Monaco, Norway, San Marino,
and Switzerland), the East (the 15 countries of the former Soviet Union),
and the Centre (the other countries of the former communist block, plus
Turkey) (table).

ResultsHIV/AIDS infection in western Europe (figures 1 to 4)
The use of powerful antiretroviral drugs on a large scale since 1996
was followed by a significant decrease in AIDS incidence and deaths
among AIDS cases. Starting in 1996, this trend became stronger in 1997,
then slowed down the following years. In 2001, AIDS incidence was 22.8
per million population (table). Decreases in AIDS cases have been less
marked among persons infected during a heterosexual intercourse ('heterosexuals')
than for other transmission groups, so that for the first time in 2001,
'heterosexuals' constituted the largest transmission group (36 %). Most
of this group were men (59 % in 2001), and a growing proportion of cases
originated from a country where the HIV epidemic generalised (from 24%
in 1997 to 34% in 20013, mainly sub-Saharan Africa.

The overall rate of new HIV diagnoses was 54.9 cases per million population
in 2001. In western countries for which such data have been available
for at least five years, the global rate of new HIV diagnoses appears
relatively stable. These data should nonetheless be interpreted cautiously
because they highly depend on testing and reporting procedures in each
country. The number of new HIV diagnoses reported per year decreased
slowly in homo/bisexual men (HBM) and injecting drug users (IDU), but
it has constantly increased since 1996 in persons heterosexually infected
(+64% between 1997 and 2001).

This increase is due to an increase in cases originating from countries
where the HIV epidemic is generalised. It has been observed in several
countries (for example Belgium, Ireland, Norway, United Kingdom), but
is more marked in the United Kingdom (+144% between 1997 and 2001),
where migrants account for 79% of reported cases heterosexually infected
in 2001. Data for the first six months of 2002 seem to confirm these
trends.
HIV/AIDS infection in central Europe (figures 1,3)

In the Centre, AIDS incidence (<6 cases per million population per
year) and the rate of new HIV diagnoses (7-10 cases per million) remain
low (table). Numbers of new HIV diagnoses in IDU are low, and almost
exclusively diagnosed in Poland (95%). Central Europe reported the majority
of paediatric AIDS cases (61%), resulting from an outbreak which occurred
in young children in Romania in the 1990s, due to blood transfusions
or multiple injections using poorly sterilised equipment.

HIV/AIDS infection in eastern Europe (figures 1,3,5,6)
In the East, the number of newly diagnosed HIV infections has dramatically
increased from 233 cases in 1994 to nearly 100 000 reported cases in
2001, representing 348.8 cases per million. In 2001, rates over 100
cases per million population were observed in four countries (Estonia,
Latvia, the Russian Federation and Ukraine), and between 15 and 75 cases
per million in eight other countries of the region. The epidemic began
in 1995 in Ukraine, then spread to the Russian Federation, Belarus and
the Republic of Moldova in 1996, Latvia in 1998, Estonia in 2000 and
Lithuania in 2002 (data not shown). All countries in this area are affected,
including Armenia, Azerbaijan, Georgia and Kazakstan, Kyrgyztan, Uzbekistan.

In 2001, the majority of these infections were diagnosed in IDU (89%
excluding cases with no reported risk), males (78%) and young people
(82% under 30). The number of cases attributed to heterosexual transmission
has also increased (+53% in 2001 compared to 2000). Inversely, the number
of cases among HBM is very low and stable (around 100 per year). For
a large and increasing number of cases, the mode of transmission is
not reported (38% in 2001).

AIDS incidence remains low (<3 cases per million inhabitants), except
in Latvia (16.9 cases per million in 2001) and in Ukraine (17.2 cases
per million in 2001) (table). Three quarters of AIDS cases in the East
are reported with pulmonary tuberculosis as AIDS indicative disease.

DiscussionWestern Europe: an endemic and concentrated situation
In western Europe, the large scale use of powerful antiretroviral drugs
has widely contributed to the decrease in new AIDS cases and deaths
among AIDS cases, especially over the two years following their availability.
Despite the increase of new HIV diagnoses in those infected through
heterosexual contact, in particular in individuals originating from
countries where the infection is generalised, IDU and HBM remain the
most affected groups in the West. The prevalence of HIV infection in
IDU was 16% in France (national survey based on self reporting of HIV
serostatus), and 31% in Spain (national survey based on diagnostic testing)
in 1999 (more recent data unavailable) (4). In HBM, HIV prevalence was
between 11 and 20% in 2000 in three large cities: Barcelona and London
(unlinked anonymous surveys) and Paris (survey based on self reporting
of HIV serostatus) (2). Moreover, the recent increase of sexually transmitted
infections in HBM in several countries of western Europe (5) suggests
a relapse of risky behaviours in this group.
The major challenges currently facing western Europe are to prevent
the slackening of safer sex practices and to improve access to HIV testing
and health care for all persons infected, especially migrants coming
from countries where the infection is generalised.

Central Europe: low level epidemic
Central Europe appears to have been relatively spared by the epidemic.
Data on AIDS incidence and new HIV diagnoses, together with data available
on prevalence in pregnant women (< 2 per 10 000) or in IDU (<
2% except for Poland where prevalence was 11% in 2000) confirm that
this region has generally escaped a large scale dissemination of HIV
(4,6-7). However, risk behaviours exist in all countries and it is therefore
crucial to maintain effective prevention measures.

Eastern Europe: recent and concentrated epidemics
Since the collapse of the Soviet bloc, the East has been faced with
an explosive HIV epidemic concentrated among IDU in an unfavourable
socio-economic context (increase in prostitution and drug use and economic
crisis). Currently, risk reduction programmes barely cover 10% of the
IDU population (7). To contain this epidemic, it is vital to increase
the coverage of these programmes. Large-scale heterosexual transmission
represents a major risk in this region. The outcome will depend on the
nature and extent of contacts between high risk populations (in this
case, IDU) and the general population. The number of infections associated
with heterosexual transmission remains low but has been increasing significantly
for 2-3 years. The low incidence of AIDS in eastern Europe reflects
partly the long incubation period of AIDS, but also underreporting in
some countries. Inevitably, the East will be faced to a massive AIDS
epidemic as a consequence of the current HIV epidemic. This may overwhelm
health care services. The HIV epidemic will probably have a negative
impact on the control of tuberculosis in this part of the world where
the prevalence of tuberculosis and multiresistant strains is already
very high, especially as HIV infection and tuberculosis mainly affect
the same populations, frequently young and socially disadvantaged.

Comparing epidemiological data on HIV/AIDS at the European level is
essential for a better understanding of the dynamics of the epidemic
and the impact of prevention programmes. It should also help towards
a better assessment of the impact of migrant populations on the HIV/AIDS
epidemic in Europe.

EuroHIV is a programme funded by the European Commission (contract
contrat N°SI2.326442 [2001CVG4-020]) within the framework of the
European Surveillance Network for Communicable Diseases, implemented
by the European Decision in 1998. We wish to thank the national correspondents
of HIV/AIDS surveillance from the 51 countries as well as all the clinicians,
biologists and health professionals who make data collection possible.

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